07100196 CITY OF CUPERTINO
BUILDIIVG DIVISION PERMIT ����������������«
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BUILDING ADDRESS: PERMI'f NO.
835 LILY AVE TBD — TC BE DETERMINED 07100196 .
pERM1T LSSUE DATE
,,.VNER'S NAME:
CHRISTOL JAMES T AND ANN E � 11/19/2007
SAMTARY NO. CONTROL NO.
PHONE:
B(J►LDING PERMIT INFO
ARCHI'IEC['/ENGiNEER: BLDG ELECI' PLUMB MECH
� � � �
q p � LICENSED CONfRACfOR DECC.nRnnoN Job Description
� V I hcrcby aflirm tAat I un licensed umler provisions oC Chaptcr 9(commcncin6
� with SccGon 7olx)) of Division 3 of ihc Busincsr and Profcssions Codc, and my liccnsc is ADD 2 7 7 S Q `I' � S F DW , RMDL K I T C HN , M S TR BDRM � I� S'1'R
�� infuliforceande(fa� ��.x BATH, FOS�ER ROOF, EXTERIOR COSMETIC, INCLUDES
� v� Z Licensc Clus Conlrxtor
='-° °atc ARCHITECI'SDECLARATION RE—ROOF & STRUCTURAL
��� I undcruanJ my plans shall bc used u pu6iic rccords
7yU
L W� y Licensed Prufcuionai
OWNER-BUiLDER DECLARA'C10N
� <� I hcrcby af(irtn that 1 am excmpt Gum tLc Coniractors Liccnm Law Cor thc
i p O following rcason. (Scction 7031.5, Busincss and Profcssions Cafc: Any city or coun�y
t,°, Pi which rcquiros a permit to rnnswct, alter. improvc. dcmolish. or �epair any swctmc
'� - y prior w i�s issuancc, also rcquircs thc applicant for such pertnit to filc a signcd s�a�cmcnt ��, Ft. Floor Area Valuation
- Z< �hat he is licensed pursuanl to il�e pmvisioaa oC ttm Contrutor's License Law (Chapter 9 •>q c� 3 O O O O O
y �� (commcncing wiU� Scauon 7000) of Division 3 of ihc Busincss and Profcssions Cadc) or '�
y �'. that he ia e�cempt the�efmm and ihe basis [or tAe allcgcd eumption. My violation ot Oecupancy Type
Section 7031.5 by a�ry sPPlicant [w a permit subjecu the applicant to a civil penalty of (� Number
not mrne U�an fiw hundmd dollars (5500)• 3 5 9 � 3 � �� 3�"
❑ i, u owncr ot ttie property, ar my employces v+ith wages u the'u solc compensadon,
w �Ild o wework.and�hesuucw�eisnotintended«otTecedforsale(Sec. 7 o 4 �t.Businesa Required Inspections
and Aofessiona Code:'lt�e Conuactor's Lianse Law daes not apply m an awner of
property who buiids or improves thercon, and who does such work himulf or through hia
awe employces, provided that such improvemrnls m not intended or otfered for sale. lt.
however, the building or impmvemuu is sold within one year oC complcuon, the ownu-
builder wiR have the borden o[ proving �Aal he did not build or improve for purpose of
sakJ.
. u owner o[ che property. am acclusively conuscting wi�h Gcensed conusctors a
eonswct the projea (Sec. 7044. Business and Professions Cade:) lbe Contracwr's Li-
ccnse Law does nol apply m an owner of property who builds or improves U+eceon, and ,
who wnuacts for such pmjecls with a comractor(s) ticensed pursuant to the Convacwrs
' 'C.EM1SC W.
1 am mpt under Sec. . B& P C for ihis resson
uwner
Da�e � �✓ ��
WORK 'S COMPENSA770N DECLARA170N
1 de y affirm under penalty of perjury one af the follawing declarmions:
❑ I hsae and wil! mainuin a Cenif cate of Consenl lo self-insme [or Workers Compen-
suion, u providcd for by Section 3700 of Uie I�bor Code, far �he perfortnanm ot the
woric for which this permit is issued.
❑ I havc and will maintain Workcr's Compensation [nsurana, az requircd 6y Section .
3700 0! the Laboc Code, Cw the performance of Ihe wort for which Nis permi� is istued.
My Workers Compenaauon Insuance cartie* snd Policy number tie:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTTON FROM W ORKERS'
COMPENSATION INSURANCE
(ihis section need not bc complctcd i( the pecmit is for onc hundred dollus (f 100) ,
m Icss.)
I cenify that in �hc performancc of thc work fw which �his permi� is issued, l shall not
nmploy any persan in m r so u to beco bject to ihe Workcrs' Compcnsation
Laws of Glifomis. D �
Applicant
NOTICE 7'O APPLIC : lf, aftcr making �his Ccrti[icau of Excmptian, yau should
becane subject to thc orter's Compcnsation prorisions of �hc lalwr Codc, you must
� O forthwiU� comply with such provisions or this pecmit shall bc dcemed �cvoked.
z �"� CONSTRUCfION LENDING AGENCY
[� r�-i I hcrc6y atfirm Uist thcre ia a conuruction Icnding agcncy (or thc perfortnancc of �
a� Ihe wurk [or which lhis pem�it is issued (Scc. 3097. Civ. C.) ,
W Q Lendcr's Nunc
? z L.cnder's Address
V 0 I cenity iha� I havc resd Utis appiicttion and suic ihu �hc above infomiatiun is
w F cortcc� I agrce a comply wiU� all ciry and county onfioances and sute laan ceiadng w
0 U building consuuction, and hereby authori�e represenutivcs of ihis city w cnter upon Ihc
� w aAove-menGo�d propcny (or in�pcc�ion pumoset
a (Wc) agree to save, indcmnify and koep harmlest lhe City oC Cupertino against
�„�� � liabilitiu, judgmcn�s, cosLS and expenscs which may in any way ucYUC againsl seid City /
V z in consequence ot IAc gnnting of �his permit. Date — (���
� APPLIC NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIM Issued by
SOUR EGULA170 • �?�(,����� Re-roofs
Sign fApplicant/Contracwr �8� Type of Roof �
HAZARDOUS MA7'ERiALS D[SCLOSURE
�II the appliant or futwc building acupan[ storc or handlc ha•r,rdous matcrial
refincd by thc Cupertino Municipal Codc. Chaptcr 9.12, and ihe Hcal�h and SaCcty
..«k SecUon 25532(a)? ,,,___.../// All roofs �hall be inspected prior to any roofing material being installed.
� y� �No
Wiil the applicant or future building accupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
emit ha•rardous air conwninan�s u JcGncd hy thc Bay Area Air Quslity Managcmem all new m aterials for inspection.
Disuict?
�ycs �]Nu
1 havc rca�i �he t�vaNcws maicris�s re9uiremcnu unJcr Chapmr 6.95 of U�e CaliCor-
nia Ficalth & Safcry Cadc, Sections 25505.25533 and 25534.1 undctsund ihu if Uu huilding
dacs no curtcnlly havc a tenan4 dwt it is my maponsibility m noufy �c occupant of thc
rcyuire n�s which must e or to issuancc of a Ccrtirica�c of Occu �� Signature of Applicant Date
��° All roof coverings to be Class "B" or better
O c r auiham.cd agcm Datc